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Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3859 (Published 23 June 2014) Cite this as: BMJ 2014;348:g3859
  1. Stephan Windecker,
  2. Stefan Stortecky,
  3. Giulio G Stefanini,
  4. Bruno R daCosta,
  5. Anne Wilhelmina Rutjes,
  6. Marcello Di Nisio,
  7. Maria G Siletta,
  8. Ausilia Maione,
  9. Fernando Alfonso,
  10. Peter M Clemmensen,
  11. Jean-Philippe Collet,
  12. Jochen Cremer,
  13. Volkmar Falk,
  14. Gerasimos Filippatos,
  15. Christian Hamm,
  16. Stuart Head,
  17. Arie Pieter Kappetein,
  18. Adnan Kastrati,
  19. Juhani Knuuti,
  20. Ulf Landmesser,
  21. Günther Laufer,
  22. Franz-Joseph Neumann,
  23. Dimitri Richter,
  24. Patrick Schauerte,
  25. Miguel Sousa Uva,
  26. David P Taggart,
  27. Lucia Torracca,
  28. Marco Valgimigli,
  29. William Wijns,
  30. Adam Witkowski,
  31. Philippe Kolh,
  32. Peter Juni
  1. Correspondence to: S Windecker Department of Cardiology, Bern University Hospital, 3010 Bern, Switzerland stephan.windecker{at}insel.ch
  • Accepted 27 May 2014

Abstract

Objective To investigate whether revascularisation improves prognosis compared with medical treatment among patients with stable coronary artery disease.

Design Bayesian network meta-analyses to combine direct within trial comparisons between treatments with indirect evidence from other trials while maintaining randomisation.

Eligibility criteria for selecting studies A strategy of initial medical treatment compared with revascularisation by coronary artery bypass grafting or Food and Drug Administration approved techniques for percutaneous revascularization: balloon angioplasty, bare metal stent, early generation paclitaxel eluting stent, sirolimus eluting stent, and zotarolimus eluting (Endeavor) stent, and new generation everolimus eluting stent, and zotarolimus eluting (Resolute) stent among patients with stable coronary artery disease.

Data sources Medline and Embase from 1980 to 2013 for randomised trials comparing medical treatment with revascularisation.

Main outcome measure All cause mortality.

Results 100 trials in 93 553 patients with 262 090 patient years of follow-up were included. Coronary artery bypass grafting was associated with a survival benefit (rate ratio 0.80, 95% credibility interval 0.70 to 0.91) compared with medical treatment. New generation drug eluting stents (everolimus: 0.75, 0.59 to 0.96; zotarolimus (Resolute): 0.65, 0.42 to 1.00) but not balloon angioplasty (0.85, 0.68 to 1.04), bare metal stents (0.92, 0.79 to 1.05), or early generation drug eluting stents (paclitaxel: 0.92, 0.75 to 1.12; sirolimus: 0.91, 0.75 to 1.10; zotarolimus (Endeavor): 0.88, 0.69 to 1.10) were associated with improved survival compared with medical treatment. Coronary artery bypass grafting reduced the risk of myocardial infarction compared with medical treatment (0.79, 0.63 to 0.99), and everolimus eluting stents showed a trend towards a reduced risk of myocardial infarction (0.75, 0.55 to 1.01). The risk of subsequent revascularisation was noticeably reduced by coronary artery bypass grafting (0.16, 0.13 to 0.20) followed by new generation drug eluting stents (zotarolimus (Resolute): 0.26, 0.17 to 0.40; everolimus: 0.27, 0.21 to 0.35), early generation drug eluting stents (zotarolimus (Endeavor): 0.37, 0.28 to 0.50; sirolimus: 0.29, 0.24 to 0.36; paclitaxel: 0.44, 0.35 to 0.54), and bare metal stents (0.69, 0.59 to 0.81) compared with medical treatment.

Conclusion Among patients with stable coronary artery disease, coronary artery bypass grafting reduces the risk of death, myocardial infarction, and subsequent revascularisation compared with medical treatment. All stent based coronary revascularisation technologies reduce the need for revascularisation to a variable degree. Our results provide evidence for improved survival with new generation drug eluting stents but no other percutaneous revascularisation technology compared with medical treatment.

Footnotes

  • Collaboration coordinating centre: Department of Cardiology, University Hospital Bern, Bern University Hospital, Bern, Switzerland and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland. Stephan Windecker, Stefan Stortecky, Giulio G Stefanini, Bruno R da Costa, Anne W Rutjes, Marcello di Nisio, Maria G Silletta, Ausilia Maione, and Peter Jüni.

  • Writing committee: Stephan Windecker, Stefan Stortecky, Giulio G Stefanini, Bruno R da Costa, Anne W Rutjes, Marcello di Nisio, Maria G Silletta, Ausilia Maione, Fernando Alfonso, Peter M Clemmensen, Jean-Philippe Collet, Jochen Cremer, Volkmar Falk, Gerasimos Filippatos, Christian Hamm, Stuart J Head, A Pieter Kappetein, Adnan Kastrati, Juhani Knuuti, Ulf Landmesser, Günther Laufer, Franz-Josef Neumann, Dimitri Richter, Patrick Schauerte, Miguel Sousa Uva, David Taggart, Lucia Torracca, Marco Valgimigli, William Wijns, Adam Witkowski, Philippe Kolh, and Peter Jüni.

  • Contributors: SW and PJ conceived and designed the study. AWR and MdN completed the literature search and coordinated the extraction of data in collaboration with MGS and AM. SW, SS, GGS, BdC, and PJ performed and interpreted the analysis in collaboration with PK, FA, PMC, JPC, JC, VF, GF, CH, SJH, APK, AK, JK, UL, GL, FJN, DR, PS, MSU, DT, LT, MV, WW, and AW. SW, SS, and PJ wrote the first draft of the manuscript. All authors critically revised the manuscript for important intellectual content and approved the final version. SW and PJ provided administrative, technical, and logistical support. SW and SS contributed equally to this manuscript. SW and PJ are guarantors of the study.

  • Funding: This study was supported by intramural funds from the Department of Cardiology, Bern University Hospital, and the Institute of Social and Preventive Medicine, University of Bern, Switzerland.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf. SW has received research grants to the institution from St Jude Medical and Biotronik. PJ is an unpaid steering committee or statistical executive committee member of trials funded by Abbott Vascular, Biosensors, Medtronic, and Johnson & Johnson. CTU Bern, which is part of the University of Bern, has a staff policy of not accepting honorariuma or consultancy fees. However, CTU Bern is involved in the design, conduct, or analysis of clinical studies funded by Abbott Vascular, Ablynx, Amgen, AstraZeneca, Biosensors, Biotronic, Boehrhinger Ingelheim, Eisai, Eli Lilly, Exelixis, Geron, Gilead Sciences, Nestlé, Novartis, Novo Nordisc, Padma, Roche, Schering-Plough, St Jude Medical, and Swiss Cardio Technologies. PS has received speakers’ honorariums from Medtronic, Biotronik, St Jude Medical, Impulse Dynamics, BioControl during the past five years. All other members of the writing committee declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: No additional data available

  • Transparency: The lead authors (the manuscript’s guarantors) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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